Beruflich Dokumente
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Learning Objectives
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Know the Facts: Undercoding and Overcoding
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Know the Facts: Undercoding and Overcoding, cont.
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Know the Facts: Undercoding and Overcoding, cont.
• History
• HPI: Description of Illness/Injury
• ROS: Review of Systems with Patient
• PFSH: Past Medical, Family, and Social History
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Know the Facts: Undercoding and Overcoding, cont.
• History of PresentIllness
• Must be documented by the provider
• 8 Elements of HPI
• Location: Chest pain
• QUALITY: Burning, dull
• SEVERITY: Better, 6 on a scale of 1-10
• DURATION: 1 week
• TIMING: Off and on, occasionally
• CONTEXT: After eating
• MODIFYING FACTORS: Took antacid
• ASSOCIATEDSIGNS/SYMPTOMS: Nausea and Vomiting, heartburn
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Know the Facts: Undercoding and Overcoding, cont.
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Know the Facts: Undercoding and Overcoding, cont.
Review of Systems
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Know the Facts: Undercoding and Overcoding, cont.
• Past Medical:
• Patient’s past medical experiences
• Trauma
• Hospitalizations
• Illnesses
• Injuries
• Surgeries
• Current medications/Dietary status
• Allergies
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Know the Facts: Undercoding and Overcoding, cont.
• Family History
• Medical history of thepatient’s family
• Health / status of parents/siblings
• High risk of disease
• History related to the chief complaint, HPI orROS
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Know the Facts: Undercoding and Overcoding, cont.
• Social History:
• Past and current social history
• Education/Occupation
• Marital status
• Living Situation
• Present or history of drug, alcohol, or tobacco use
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Know the Facts: Undercoding and Overcoding, cont.
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Recap
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Recap, cont.
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Recap, cont.
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References
• www.cms.gov
• www.supercoder.com
• AMA CPT®2018
• AMA Medical Record Auditor
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https://www.supercoder.com/medical-
coding-webinars/power-up-your-primary-
care-coding
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